Welcome to FamilyGuidanceCenter!

In order for us to serve you in the most effective way, we are asking you to complete the attached forms in the order they are clipped together. After you have read the forms, please sign and date them.

If you have any questions, please ask the therapist during your session.

Thank you.

FAMILYGUIDANCECENTER

Notice of Privacy Practices

This Notice describes how medicalinformation

about you may be used and disclosed and

how you can get access to this information.

Please review this Notice carefully.

This Notice of Privacy Practices serves several purposes. It describes: 1) How we may use and disclose your health information, 2) Your rights regarding your control of, and access to, your health information, and 3) Our organization’s legal duties regarding our use and disclosure of health information, and our practices related to protecting the privacy of all health information.

We are committed to protecting the privacy of your health information. In providing health care services, we will create and maintain records regarding you and the treatment and services that we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this Notice, and to abide by all terms of this Notice. This Notice will be posted at all of our physical service delivery sites, and will be posted on our web site if we maintain one. We reserve the right to update this Notice as appropriate, and to make the provisions of the updated Notice effective for all health information that we maintain.

If you have any questions or concerns about this Notice of Privacy Practices, contact our Privacy Officer at: 610-374-4963

How We May Use and Disclose Your Health Information

The following information describes how we may use and disclose your health information. It contains some examples, but this should not be considered an exhaustive list, and some examples may not apply to your situation.

Treatment: We will use your health information to provide treatment and services to you. The health information obtained about you by our staff will be recorded in your health record and will be used to determine the best course of treatment for you. If medically necessary, we may write a prescription for you. Also, any staff involved in your care will share information about you with each other, but only to the minimum extent necessary.

Payment: We will use and disclose your health information to prepare, submit and/or process bills to you or your insurer.We may contact your insurer to determine your eligibility for services, and we may provide your insurer with information regarding your treatment and the services that we provide to you. The information we use on a bill may include information that identifies you, as well as your diagnosis, services performed and/or supplies and equipment furnished to you.

Health Care Operations: We will use and disclose your health information in the course of our day-to-day operations. Certain members of our staff may use your health information to assess the quality of the services that we provide to you, and to conduct normal business planning activities.

Contacting You: We may use your health information to contact you in order to: 1) Remind you of a scheduled appointment, 2) Reschedule an existing appointment, 3) Talk to you about a missed appointment, 4) Inform you about potential treatment alternatives or other health-related information, 5) Talk to you about an outstanding balance owed to us, and 6) Advise regarding issues related to the services that we provide to you or the seeking payment for those services.

Business Associates: In some instances, we may utilize external vendors, such as the answering service, – referred to as “business associates” –who will provide services to us in support of our operations. We may disclose your health information to these“business associates”so that they can perform the tasks for which they have been contracted. Please be aware that we require our “business associates” to appropriately safeguard all health information which has been disclosed to them.

Directory of Individuals: Unless you object, we may maintain information about you in the form of a list/directory. The list/directory will allow us to identify the site where you receive services, and is used for internal operational purposes only.

Family, Relatives, and Others: Upon obtaining your written authorization, we may disclose your health information to family, relatives, your primary care physician, and other persons identified by you, but only the health information which is directly relevant to their involvement, care, and/or payment activities pertaining to you.

Notification in Case of Emergency: Our staff, using its best judgment, may use or disclose health information about you to notify or assist in notifying a family member, personal representative, or another person/entity/health care providerin the case of an emergency.

Deceased Individuals: We may disclose health information that is consistent with applicable law to funeral directors, medical examiners, coroners, executors of your estate, and others as allowed by law so that they may carry out their duties.

Marketing: We may use your health information for “marketing” purposes, but only after obtaining your written authorization to use your health information.

Fundraising: We may use your health information for our internal fundraising activities. If we conduct fundraising activities, you have the right to have your name removed from the solicitation list. You are not obligated to participate or support any fundraising activity. If you wish to have your name removed from our solicitation list once you have been contacted, please ask a staff member for assistance.

Court Orders: We may disclose your health information pursuant to a court order issued by a court of competent jurisdiction.

Suspected Abuse, Neglect, or Domestic Violence: We may disclose your health information, as required or allowed by law, if we suspect abuse, neglect, or domestic violence, but only to entities authorized to receive such reports.

Licensing and Accreditation Organizations: We may disclose your health information pursuant to licensing and accreditation activities to maintain the health, safety and welfare of the people we serve and/or to promote quality outcomes.

Correctional Institution: Should you become an inmate of a correctional institution or be placed under supervision of the juvenile or adult criminal court, we may disclose to the institution or agents thereof, probation or parole officer or their designees, health information necessary to preserve or maintain your health and the health and safety of other individuals.

Law Enforcement: We may disclose your health information for certain law enforcement purposes, as required or allowed by law.

Health Oversight and Public Health Activities: We may disclose your health information to appropriate health oversight agencies, and for the purposes of preventing or controlling disease, injury, or disability, as required or allowed by law.

To Avert a Serious Threat to Health or Safety: We may disclose your health information, with certain exceptions, in order to avert a serious threat to the health or safety of you or others.

Disclosures Required by Law: We may disclose your health information in other circumstances, as required by regulation or law.

Your Privacy Rights Pertaining to Your Health Information

Although your health record remains the physical property of our organization, the information contained in our records belongs to you. You have numerous rights regarding your health information.

Written Authorization for Disclosure of Health Information: When required by regulation, law, or our internal privacy practices, we will obtain your written permission prior to disclosing your health information to persons/entities outside of our organization. This permission will be obtained using an Authorization to Disclose Health Information form. You have the right to refuse to sign any Authorization, and the right to revoke a previously signed Authorization. Please make sure that you carefully read the Authorization form prior to signing it.

Confidential Communications: You have the right to request that we contact you at a certain location, or in a certain manner. As an example, you may request that we use an alternate address or phone number to contact you. We will attempt to accommodate reasonable requests, but we are not required to do so. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.

Requesting Restrictions to Our Uses and Disclosures: You may request that we use or disclose your health information in a certain way related to our treatment, payment, and health care operations activities. As an example, you may request that we not disclose your health information to a particular person. Please be aware that we are not required to agree to a requested restriction, but if we do agree to a request we are bound by our agreement except in emergency circumstances and certain other situations. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.

Access to Your Health Records, and Obtaining Copies: You may request to review and obtain a copy of certain of your health records. We may deny your request under limited circumstances, however, you may request a review of certain denials. If you request and are granted a copy of your health records, we may charge you a reasonable cost-based fee. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.

Amendment of Your Health Records: You may request an amendment to certain of your health information if you believe it is incorrect or incomplete. We may deny you request under certain circumstances. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.

Disclosure Accounting: You may request an accounting of certain disclosures that we have made regarding your health information. The first accounting requested within a 12-month period will be provided at no charge. We may charge a reasonable cost-based fee may be charges for all additional requests received within that same 12-month period. We have developed a form for this request. Please speak to one of our staff if you have a question regarding this right.

Receiving a Copy of This Notice: You are entitled to receive a copy of this Notice at any time. To obtain a copy, please inquire at any of our service delivery sites, or speak to one of our staff. Additionally, if we maintain a website, we will make this Notice available on the website.

Filing a Complaint: You may file a complaint with us, or with the Federal Government, if you believe that your privacy rights have been violated. Review the section below entitled “Requesting Assistance, Asking Questions, and Filing Complaints” in order to determine how to file a complaint.

Our Duties and Responsibilities

We will not use or disclose your health information without your consent and/or authorization, except as allowed by law and as described in this Notice. We are required by law to maintain the privacy of your health information, and to provide you with a Notice as to our legal duties, and our privacy practices, with respect to the information we collect and maintain about you. We are required to abide by the terms of this Notice, to notify you in writing if we are unable to agree to a requested restriction on the use of your health information, and to accommodate reasonable requests made by you to communicate health information by alternative means or to alternative locations. We reserve the right to change our privacy practices at any time, and to make the new provisions effective for all protected health information that we maintain.

Requesting Assistance, Asking Questions, and Filing Complaints

If you have questions, would like additional information about our privacy practices, or experience a problem, you may contact our Privacy Officer at 610-374-4963. If you believe your privacy rights have been violated, you can file a complaint with the our Privacy Officer, or with the Secretary of Health and Human Services, U.S. Department of Health and Human Service, 200 Independence Avenue S.W., Washington, D.C. 20201. You may also contact the United States Office of Civil Rights. There will never be any type of retaliation for making an inquiry or for filing a complaint, and you will never be asked to waive your right to make a complaint or report a problem as a condition of receiving services from us.

Effective Date: April 14, 2003

Notice of Privacy Practices

I acknowledge that I have received a copy of [PROVIDER] Notice of Privacy Practices.

______

Client Name (Please Print)

______

Client SignatureDate

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Parent/Legal Guardian SignatureDate

(for client under 14)

Revised 12/03

FAMILYGUIDANCECENTER

CLIENT’S CONSENT TO TREATMENT

RIGHTS AND RESPONSIBILITIES POLICY

The staff at FamilyGuidanceCenter are dedicated in providing the best quality services to our clients and their family. In doing so we want to educate you regarding your rights and responsibilities.

YOUR RIGHTS AS A CLIENT

  1. To retain all civil rights and liberties as provided by law.
  1. To be treated with dignity regardless of race, color, creed, religion, national origin, ancestry, ethnicity, gender, sexual orientation, marital status, age or physical/cognitive challenge and shall not be excluded or denied services.
  1. To know your specific diagnosis, proposed treatment and any risks explained to you by your therapist and to actively participate in the development of your treatment plan.
  1. To be able to inspect your records with the therapist or other staff present, subject to the following limitations:
  1. A licensed healthcare professional may temporarily remove portions of the records prior to the inspection by you if he/she determines that the information may be detrimental if presented to you. Reasons for removing sections, homicide, suicide or reasonable likelihood of physical endangerment to self or others, shall be documented and kept on file.
  1. By letter, you have the right to appeal a decision limiting access to your records to the Executive Director. The Executive Director will get back to you via letter within 30 days of receipt of your letter.
  1. By letter to the Executive Director, you have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from your records. The Executive Director will get back to you within 30 days of receipt of your letter.
  1. By letter to the Executive Director, you have the right to submit rebuttal data or memoranda to your own records. The Executive Director will get back to you within 30 days of receipt of your letter.
  1. To be made aware of any service charges if there is a change in your payor source.
  1. To be able to terminate services unless so ordered by a court of law that attendance is mandatory.
  1. If at any time you have a complaint, please address your concern in the following sequence:

A.Speak with your therapist.

B.You may initiate a complaint orally or in writing to the Clinical Director. The Clinical Director shall respond in writing within 48 hours of receipt of the complaint. You may choose to appeal this decision within 10 days of receipt.

  1. If you continue to be dissatisfied, you may present your concern in writing to the Executive Director of FamilyGuidanceCenter within two weeks.

Executive Director

FamilyGuidanceCenter

1235 Penn Avenue, Suite 206

Wyomissing, PA. 19610

  1. To be assured of confidentiality of client identity and records.

YOUR RESPONSIBILITY AS A CLIENT

  1. To actively work with the professional staff towards the completion of your psychosocial assessment. If deemed appropriate and necessary, further assessment(s) may be suggested through psychiatric and/or psychological evaluation/testing.
  1. To actively participate in the development and implementation of your treatment plan. This includes continually reassessing your plan’s objectives and goals.
  1. To comply with FamilyGuidanceCenter’s policies and plans that include but are not limited to the client attendance policy, the client discharge policy and client treatment plan.
  1. To give your counselor 24 hours advance notice if you cannot keep your scheduled appointment.
  1. To inform the receptionist if there are any changes such as a telephone number, a new residence, a different employer or a change in insurance carrier.
  1. To meet your financial obligations for the services. If your check is returned to FamilyGuidanceCenter for non-sufficient funds, we must now charge you $20 for the returned check.
  1. To maintain confidentiality of others.
  1. I have been informed of the criteria for admission, treatment, completion and discharge.

I , acknowledge the above and agree to adhere to the client’s rights

Print name of client

and responsibilities policy to the best of my ability. I hereby consent to have treatment provided to me. I accept / refuse (circle one) a copy of this policy agreement.

______/____/____

Signature of Client or Client’s Parent/Guardian Today’s Date

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Therapists Signature

Original:

Revised 08/02; 04/03; 11/04; 01/05

FamilyGuidanceCenter

Attendance/Discharge Policy

The Staff at FamilyGuidanceCenter is dedicated to providing the highest quality service to our clients and their family. Consistent attendance and active participation in treatment is required to obtain the optimal treatment outcome. To adhere to this policy we ask that you acknowledge the following guidelines:

  1. If you must cancel a session, please give FamilyGuidanceCenter at least 24 hours notice. Please call your therapist to make them aware of your circumstances.
  2. If you do not call to cancel a session or call less than 24 hours before your scheduled session, it is considered a NO SHOW. Two consecutive NO SHOWS or three nonconsecutive NO SHOWS may result in your case being closed.
  3. If you have excessive cancellations (3 or more within a 2 month period) it may result in your case being closed unless there are extraordinary circumstances.
  4. If you miss an appointment with the Doctor, prescription renewal cannot be guaranteed. Medications can be an important part of treatment. The Doctor needs to see you to evaluate the medications and ensure optimal results. Phone in prescriptions will only be considered one time in a 12 month period.

Discharge may also be the result of, but not limited to, the following: